BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: SB 1361 --------------------------------------------------------------- |AUTHOR: |Nielsen | |---------------+-----------------------------------------------| |VERSION: |February 19, 2016 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |April 13, 2016 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Scott Bain | --------------------------------------------------------------- SUBJECT : Medi-Cal: eyeglasses SUMMARY :1. Provides Medi-Cal coverage of one pair of eyeglasses provided every two years for an individual who is 21 years of age or older and who is unable to meet or exceed the driver's license vision standards established by the Department of Motor Vehicles. Existing law: 1)Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS) and under which qualified low-income persons receive health care benefits. 2)Establishes a schedule of benefits under the Medi-Cal program. Excludes specified optional benefits from coverage under the Medi-Cal program, including optometric and optician services, including services provided by a fabricating optical laboratory, except for beneficiaries under the Early and Periodic Screening Diagnosis and Treatment Program (individuals under age 21), and beneficiaries receiving long-term care in a nursing facility that is a skilled nursing facility or intermediate care facility that is licensed as a nursing facility. Optometry services in Medi-Cal were reinstated (eye exams and procedures by optometrist) for adults 21 and over in July 2010. 3)Prohibits the Department of Motor Vehicles (DMV) from issuing or renewing a driver's license to any person whose best corrected visual acuity is 20/200 or worse in that person's better eye, as verified by an optometrist or ophthalmologist. This bill: 1)Provides Medi-Cal coverage of one pair of eyeglasses provided every two years for a Medi-Cal eligible individual who is 21 SB 1361 (Nielsen) Page 2 of ? years of age or older and who is unable to meet or exceed the driver's license vision standards established by DMV. 2)Permits DHCS to seek approval of any necessary state plan amendments to implement this bill, 3)Implements this bill only to the extent that federal financial participation is available and any necessary federal approvals have been obtained. 4)Permits DHCS to implement this section by means of all-county letters, provider bulletins, or similar instructions, without taking further regulatory action. FISCAL EFFECT : This bill has not been analyzed by a fiscal committee. COMMENTS : 1)Author's statement. According to the author, many low income Californians in need of eyeglasses lack the money to buy them. Working Californians who have impaired vision are not able to fulfill their job duties effectively or safely. Californians who failed the DMV's vision exam struggle each time they drive. Restoring this service will keep people safer on the road. Adults who are striving to go back to school or college are not able to see well in class and will perform beneath their capabilities. By restoring Medi-Cal's coverage for one pair of eyeglasses every two years, Californians can get back to work or school and be able to drive safely. People who are on the Medi-Cal system often do not have the financial resources to meet basic needs. According to Dr. Karrin Vallin, the majority of her low-income patients come in for exams but they simply do not have the money to purchase glasses for themselves, and it is a low priority over the needs of their children. By restoring the coverage of eyeglasses, low income individuals will be encouraged to visit their optometrists more regularly. Eye exams can detect a number of ocular and systemic diseases such as glaucoma, diabetes and hypertension. Early detection of such illnesses can reduce cost to our overall health system. Often patients are discouraged from getting an exam, knowing they can't get glasses. SB 1361 (Nielsen) Page 3 of ? 2)Medicaid optional and mandatory benefits. States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. States are required to cover certain "mandatory benefits," and can choose to provide other "optional benefits" through the Medicaid program, for which they can receive federal financial participation (federal "matching funds"). The federal Centers for Medicare and Medicaid Services indicates the following are mandatory and optional benefits in Medicaid: ---------------------------------------------------------------- | | | | Mandatory Benefits | Optional Benefits | | | | |--------------------------+-------------------------------------| | | | | Inpatient | Prescription drugs | | hospital services | | | | | | | Clinic services | | Outpatient | | | hospital services | | | | Physical therapy | | | | | Early and | | | Periodic Screening, | Occupational therapy | | Diagnostic, and | | | Treatment Services | | | (EPSDT). | Speech, hearing and language | | | disorder services | | | | | Nursing facility | | | services | Respiratory care services | | | | | | | | Home health | Other diagnostic, screening, | | services | preventive and rehabilitative | | | services | | | | | Physician | | | services | Podiatry services | | | | | | | SB 1361 (Nielsen) Page 4 of ? | Rural health | Optometry services | | clinic services | | | | | | | Dental services | | Federally | | | qualified health | | | center services | Dentures | | | | | | | | Laboratory and | Prosthetics | | X-ray services | | | | | | | Eyeglasses | | Family planning | | | services | | | | Chiropractic services | | | | | Nurse Midwife | | | services | Other practitioner services | | | | | | | | Certified | Private duty nursing | | Pediatric and Family | services | | Nurse Practitioner | | | services | | | | Personal Care | | | | | Freestanding | | | Birth Center | Hospice | | services (when | | | licensed or | | | otherwise recognized | Case management | | by the state) | | | | | | | Services for individuals age | | Transportation to | 65 or older in an Institution | | medical care | for Mental Disease (IMD) | | | | | | | | Tobacco cessation | Services in an intermediate | | counseling for | care facility for the mentally | | pregnant women | retarded | | | | | | | | | State Plan Home and | SB 1361 (Nielsen) Page 5 of ? | | Community-Based Services - | | | 1915(i) | | | | | | | | | Self-Directed Personal | | | Assistance Services - 1915(j) | | | | | | | | | Community First Choice | | | Option - 1915(k) | | | | | | | | | Tuberculosis Related | | | Services | | | | | | | | | Inpatient psychiatric | | | services for individuals under | | | age 21 | | | | | | | | | Other services approved by | | |the Secretary* | | | | | | | ---------------------------------------------------------------- *This includes services furnished in a religious non-medical health care institution, emergency hospital services by a non-Medicare certified hospital, and critical access hospital. 1)Background on Medi-Cal optional benefit elimination. In 2009, the Legislature and Governor enacted AB 5 (Committee on Budget, Chapter 20, Statutes of 2009), which eliminated some optional benefits for adults that had been covered under Medi-Cal. Optional benefits eliminated by AB 5 were acupuncture services, audiology and speech therapy services, chiropractic services, optometric and optician services, including services provided by a fabricating optical laboratory, podiatric services, psychology services, and incontinence creams and washes. When the state eliminated optional benefits, services that were previously provided by an acupuncturist, podiatrist, a psychologist, which are no longer covered by Medi-Cal can still be provided by a physician. DHCS indicates its optional benefit exclusion SB 1361 (Nielsen) Page 6 of ? policy also allows certain populations (pregnant women and beneficiaries under 21 years old) to continue to receive these optional services. DHCS also indicates all Medi-Cal eligible beneficiaries can access optional benefit services in certain settings, such as hospital outpatient departments or emergency rooms, and some optional services (such as podiatry and chiropractic services) can be received in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). Most of the General Fund savings from the optional benefit elimination in AB 5 resulted from the elimination of adult dental. Litigation brought by RHCs resulted in podiatry and other services being reinstated at RHCs and FQHCs. Optometry services were reinstated (eye exams and procedures by optometrist) to adults 21 and over in July 2010, but all eye appliances (glasses, contact lenses, low vision devices) and dispensing optician services, including services provided by fabricating optical laboratories for adults 21 and over, are still excluded from coverage. Psychology services were reinstated in January 1, 2014, and last session, the Legislature and Governor reinstated some adult dental services in AB 82 (Budget Committee, Chapter 23, Statutes of 2013), the 2013-14 budget health trailer bill. The Legislative Analyst's Office estimates the General Savings from the elimination of the optician/optical lab services benefit in Medi-Cal is $4.9 million in 2015-16. 2)Prior legislation. AB 1868 (Gomez of 2013), would have provided Medi-Cal coverage of medical and surgical services provided by a podiatrist within his or her scope of practice that, if provided by a physician, would be considered physician services, for services which can be provided by either a physician or a podiatrist. AB 1868 was held on the Senate Appropriations Committee suspense file. 3)Support. This bill is supported by VSP Global and the California Optometric Association (COA). COA argues a recent study by Ingenix Consulting shows individuals with eyeglass coverage are at least two times more likely to receive a comprehensive eye exam compared to those who do not have eyeglass coverage. Restoring the eyeglass benefit for adults in the Medi-Cal program means they would be more likely to receive an eye exam, which often leads to early diagnosis of diabetes, heart disease and high blood pressure - major cost drivers in California's health care system. Early diagnosis SB 1361 (Nielsen) Page 7 of ? means lower treatment cost for these conditions and better patient outcomes. COA states eye care is a small fraction of the health care market with a far-reaching impact because if someone cannot see, he/she will have a more difficult time finding work, driving, cooking, and ultimately have a higher chance of disability. A study found that individuals with vision problems are more likely to experience social isolation and a greater tendency to have other health problems. A pair of eyeglasses can make all the difference in helping individuals to regain their confidence and live independently. As the aging population rapidly grows, vision problems and eye-related diseases are expected to double. 4)Policy questions. a) In 2014-15, the Senate version of the budget proposed to restore the optional benefits eliminated in 2009, but this proposal was not included in the final budget agreement. Several optional benefits eliminated by AB 5 have since been restored, but other important benefits, including podiatry and glasses and contact lenses, have not been. Which Medi-Cal optional benefits should be restored? b) This bill would restore Medi-Cal coverage of one pair of eyeglasses provided every two years for an individual who is 21 years of age or older and who is unable to meet or exceed the driver's license vision standards established by DMV. The DMV's vision screening standard is the ability to see 20/40 with both eyes together, with or without corrective lenses. Individuals with extremely poor vision (visual acuity of 20/200 or worse), may not be scheduled for a drive test. Existing Medi-Cal regulations already contain a vision standard which makes it easier for beneficiaries to obtain glasses. One proponent of this bill (an optometrist) explains the rationale for the standard in this bill is the previous Medi-Cal adult vision standard resulted in people with lessor vision prescription needs being eligible, but who do not really need a correction. Should this vision benefit restoration be limited to individuals who meet this DMV vision standard or should the current Medi-Cal standard apply? SUPPORT AND OPPOSITION : Support: American Federation of State, County and Municipal Employees, AFL-CIO Association of California Healthcare Districts SB 1361 (Nielsen) Page 8 of ? California Optometric Association County Health Executives Association of California National Association of Social Workers-California Chapter VSP Global, Inc. Western Center on Law & Poverty An individual Oppose: None received -- END --